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SAN JOADU# 'NTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL ON DIVISION <br /> UST WORKSHEET FOR SITS CLOSURE EVALUATION ATE <br /> AME OF FAC(IILITY /1 A S FRV I� /✓, � ECORD ID �3 `�, �- <br /> J f0 C_ 1 T Lam- " ANK ID <br /> ANK SIZE ' O UEL TYPE Lv ©� J'tOG�D; G� r)Ir <br /> 11, GENERAL SITE HISTORY / <br /> [s permit current? esIV o ermit # - acility Status Code oc.Soil/GW Cant es o <br /> umber of Tanks at facility ge of Tank(if available) __Type of Tank teal Fbrgl ngl. I Dual <br /> 111. TANK HISTORY <br /> as Tank tested? es o ailed precision test ? Fe <br /> s o [f yes, give date(s) <br /> as a repair made to the tank system? es I Na I f yes, what was repaired? <br /> as repair done under inspection? es o ere soil samples analyzed? es o TXE PH-G PH-O h/EDe <br /> ype of failure/discharge atastrophic Long-teen leakage verfill n Cher: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Sail Samples Received as o epth to Ground Vater of/Year verage Amua( Precipitation = 4 0-25 <br /> On-Site Well(s7 es o umber & Type Irr am <br /> S core S core 5 core <br /> Distance to Wells) from Tank ft; ft; ft C 0 pts C pts C pts <br /> O f 0 if 0 'f <br /> R ondition R ondition R ordition <br /> Site Feature - Leaching Potential Analysis E -s met E is met E 's mei <br /> inimum Depth to groundwater from the Soil Sample (feet) >100 1-100 25-50L1 <br /> Fr3coures in subsurface (applies to foothills or mountain areas) None Unknown resent <br /> verage Annual Precipitation (inches) xxxx <10 9 10-25 Kxxxxxx 26-40L <br /> an-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds) More Unknown resent <br /> pique site features: Recharge area, coarse soil, or wells. At least 4ore than <br /> 'Muncipal=>2000 ft; domestic=>500 ft; irr/agricut tura l=present) xxxx None one one <br /> COLUMN TOTALS>»TOTAL POINTS ' <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> i% . o67 EH- • 0` Y 8 T X E B T X E <br /> D, o(( JX' •''` ( MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 NAL <br /> ample Result: SOLINE 1000 100 10 <br /> .I }1 D.-.�� T PH AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> IESEL 10,000 1000 100 <br /> OOTNOTES: ."Jf documented soil and/or ground water contamination is present, do rwt complete the leaching potential <br /> analysis. (i.e., site is currently on UST Contamination List for soil or grovel water.) <br /> \1 If depth is > 5 ft. and < 25 ft., score 0 points. if depth m5 ft., do not use table. <br /> \2 If precipitation is > 40 inches, score 0 points. <br /> \3 Levels for BTX8E are not applicable at a TPH concentratii On of 10 ppm (gasoline) or 110`0' Ppm (dieseL)- <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> +, are BTX & "e or TPH Concentrations > Allowable Levels Yes o S�U GVR) I C <br /> � <br /> L <br /> -- o S t <br /> 2. Recommend Site Closure es o If Yes, Refer to Site Mitigation for Evaluation r— <br /> V11. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/LEAD SENIOR <br /> ONCUR <br /> WITH STAFF RECOMMENDATION FOR CLOSURE ES 0 EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 S B- <br /> ATE REF-ERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/94 <br />